CMS and New York Partner to Coordinate Care for Medicare-Medicaid Enrollees
Overview
On August 26, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that the State of New York will partner with CMS to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience.
Under the demonstration, known as “Fully Integrated Duals Advantage” (FIDA), New York and CMS will contract with Medicare-Medicaid Plans to coordinate the delivery of covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.
Medicare-Medicaid Enrollees
Improving the care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees – sometimes referred to as “dual eligible individuals” – is a priority for CMS.
Currently, Medicare-Medicaid enrollees navigate multiple sets of rules, benefits, insurance cards, and providers (Medicare Parts A and B, Part D, and Medicaid). Many Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health and long-term supports and services.
The Financial Alignment Initiative – Partnerships to Provide Better Care
Through the demonstrations approved under the Financial Alignment Initiative (Initiative), CMS seeks to provide Medicare-Medicaid enrollees with a better care experience by offering a person-centered, integrated care initiative that provides a more easily navigable and seamless path to all covered Medicare and Medicaid services.
In July 2011, CMS announced the opportunity for states to partner with CMS through one of two models:
- Managed Fee-for-Service Model in which a state and CMS enter into an agreement by which the state would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid;
- Capitated Model in which a state and CMS contract with health plans or other qualified entities that receive a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.
New York is the seventh state to establish a Memorandum of Understanding (MOU) with CMS to participate in the Initiative. CMS continues to work with other states to develop their demonstration models. All demonstrations will be evaluated to assess their impact on the beneficiary’s care experience, quality, coordination, and costs.
The New York Demonstration
Under this capitated model demonstration, an estimated 170,000 Medicare-Medicaid enrollees in New York will have an opportunity for more coordinated care. New York and CMS will contract with health plans known as “FIDA Plans” that will oversee the delivery of covered Medicare and Medicaid services for Medicare-Medicaid enrollees in New York City, Long Island, and Westchester County.
Under New York’s demonstration, all participating plans will be Medicaid Managed Long Term Care plans that modify their offerings to include Medicare services. The majority of beneficiaries eligible for enrollment are currently enrolled in Medicaid Managed Long Term Care plans and receiving community-based long-term services and supports. Medicare-Medicaid enrollees requiring facility-based long-term services and supports are also eligible for the demonstration.
All participating plans must first meet core Medicare and Medicaid requirements, state procurements standards and state insurance rules (as applicable). Every selected Medicare-Medicaid Plan must also pass a comprehensive joint CMS-state readiness review.
Integrated Appeals System
New York’s demonstration also includes an integrated appeals process that provides beneficiaries with an opportunity to address denials of items and services through a unified process that includes all Medicare and Medicaid protections. This streamlined appeals process will reduce confusion for Medicare-Medicaid enrollees who would otherwise have to navigate both the Medicare or Medicaid appeals paths, or both. It also allows for greater continuation of Medicare benefits pending appeals than currently is available.
Putting the Beneficiary First
Under the demonstration, care coordination services will be available to all enrollees. Medicare-Medicaid Plans will offer an interdisciplinary care team to ensure the integration of the member’s medical, behavioral health, long-term services and supports, and social needs. The team will be person-centered and built on the enrollee’s specific preferences and needs.
The new demonstration includes beneficiary protections to ensure that enrollees receive high-quality care. CMS and New York have established a number of quality measures relating to the beneficiary overall experience, care coordination, and fostering and supporting community living, among many others. In addition, the demonstration includes continuity of care requirements to ensure that beneficiaries can continue to see their current providers during transitions into the demonstration health plan. Ombudsman services will support individual advocacy and independent systematic oversight for the demonstration, with a focus on compliance with principles of community integration, independent living, and person-centered care.
Enrollment will be phased in over several months. Beneficiaries receiving community-based long-term services and supports will be able to opt in to the demonstration beginning no earlier than July 1, 2014. Beginning no earlier than September 1, 2014, eligible beneficiaries who have not made a choice to opt in or out will be assigned to a Medicare-Medicaid Plan through a process that will match beneficiaries with the most appropriate plan. Beneficiaries receiving facility-based long-term services and supports will be able to opt into the demonstration beginning no earlier than October 1, 2014. Those who have not made a choice to opt in or out will be assigned to a Medicare-Medicaid Plan beginning no earlier than January 1, 2015. Beneficiaries will be able to opt out of the demonstration or select an alternative Medicare-Medicaid Plan at any time.
Comprehensive Evaluation
CMS is funding and managing the evaluation of each state demonstration. CMS has contracted with an external independent evaluator, RTI International (RTI), to measure, monitor, and evaluate the impact of the demonstrations, including impacts on Medicare and Medicaid service utilization and expenditures. The evaluation for New York’s demonstration will measure quality, including overall beneficiary experience of care, care coordination, care transitions, and support of community living in New York. RTI will develop a unique, New York-specific evaluation using a comparison group to analyze the impact of the demonstration.
A Transparent Process Supporting Public Input
The New York demonstration is the product of an ongoing planning and development process through which the public helped shape the demonstration’s design. New York:
- Worked with a diverse group of stakeholders including providers, health plans, nursing facilities, hospitals, state agencies, advocacy groups, associations, and individuals.
- Collaborated with CMS to engage with local partners to ensure a broad range of perspectives were captured in the overall demonstration.
- Hosted numerous public forums to solicit public involvement including statewide calls and public meetings.
- Established public workgroups with external stakeholders to inform demonstration development and policy.
- Created and maintained a website to facilitate public participation in the demonstration design and planning process: http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm.
- Posted its draft proposal for public comment and incorporated the feedback into its demonstration proposal before officially submitting it to CMS. The proposal was then posted by CMS for public comment.
- Posted an amendment to the proposal requesting public comment on modifying the target population and timeline for the demonstration.
Additional Information
The demonstration will be administered under the Center for Medicare and Medicaid Innovation authority. Additional information about the New York demonstration, including the MOU, is publicly available at: www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html
The Memorandum of Understanding can be found at: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/NYMOU.pdf
Additional information on the ongoing development and implementation of the New York demonstration is available at: http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm.